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3 <br /> Do you want to be considered for Regional Benefit Bonus Points? p YES ❑NO <br /> If yes,list the names and PWSID#'s for each water system that will directly benefit from the <br /> project. <br /> Name: <br /> Alderwood Water District PWSID#: 01300E <br /> Name: <br /> Mukilteo Water District PWSID#: 57550J <br /> Name: <br /> City of Marysville PWSID#: 51900C <br /> Snohomish County PUDPWSID#: 809071 <br /> Name: - <br /> Name: <br /> Silver Lake Water District PWSID#: 79250B <br /> Signature of Authorized Official Date <br /> (Consultants are not authorized to signed—signature must be water system owner or water system board <br /> member) <br /> Print,sign, and send four(4) copies(unbound)of your application along with one(1)copy of your WSP, <br /> SWSMP,or Amendment postmarked by March 1,2011 to: <br /> Eloise Rudolph <br /> Department of Health <br /> Office of Drinking Water <br /> PO Box 47822 <br /> Olympia,WA 98504-7822 <br /> Be sure to include in your application the required EZ1 form along with the required map.We will not accept <br /> e-mailed applications.You may mail or deliver the application by March 1, 2011. <br /> If you need any help with this form, please contact Eloise Rudolph at(360) 236-3124 or by e-mail at dwsrfAdoh.wa.gov <br /> If you need this publication in alternate format, call (800) 525-0127. For TTY/TDD,call (800) 833-6388. <br /> DOH Form 331-201 (Rev.10110) <br /> 6 <br /> 9 <br />